Feature

The National Institute of Mental Health (NIMH) and its grantees may be facing lean times. After five years of dramatic budgetary increases--the institute's funding nearly doubled from 1996 to 2001--the projected NIMH budget for fiscal year 2004 reflects only a 3.7 percent increase from 2003. And this reduction in funding growth comes at a time when the cost of grants is steadily increasing.

To deal with the anticipated slow growth of the institute, NIMH director Tom Insel, MD, appointed in 2002, plans to refocus the mission of NIMH on, as he puts it, "alleviating the burden of mental illness." This focus on psychopathology, some say, is a sharp departure from the institute's broader mission of promoting mental health and sponsoring research in the behavioral sciences.

To understand the institute's plan for the future and how it will influence the findings in various fields of psychological research, the Monitor spoke with Insel about his vision for NIMH.

Q. You have been quoted as saying that the mission of NIMH is to reduce the burden of mental illness and behavioral disorders. Can you elaborate on what you mean by this?

A. The term burden is a little unfortunate because in some cases it has a pejorative connotation. It's actually a public health term, which refers, usually, to a new metric that is called the "disability adjusted life-year." It's a combination measure of premature death and disability. It's a way of monitoring what is the public health impact of various medical illnesses. So when I say "reduce the burden of mental illness and behavioral disorders," I'm thinking very specifically about a burden defined in that context.

The magnitude of that effect has been already measured by the World Health Organization in a study of the global burden of disease that was published in 2001. At that point, if one looked at the developed world and asked what contributes the greatest amount of burden, measured by the disability adjusted life-year for all illnesses, four of the top five in the developed world for people ages 15 to 44 are mental and behavioral disorders. So what we have here is a huge public health challenge. The mission of the institute is to find a way to reduce that particular public health burden.

Q. Will research on mental illness be prioritized by this burden metric?

A. Well that metric is a way of defining the burden. I am not sure I'd prioritize illnesses specifically that way for research because there are some places where we have more traction than others, but certainly it's a way of putting into perspective the greatest public health needs.

Q. Is it also the institute's mission to promote mental health?

A.I would put it this way: The National Institutes of Health (NIH) in general is a public health agency devoted to biomedical research, and NIMH is one of the 27 institutes and centers within the NIH. If you look at the various NIH institutes, there are some that are resource-oriented, such as the National Institute of General Medical Sciences. There are some that are oriented toward normal development, such as the National Institute of Child Health and Human Development or the National Institute on Aging. And there are some that are disorder focused...the National Cancer Institute and the National Institute of Allergy and Infectious Diseases. From my perspective, the NIMH is one of the latter. It's one of the institutes with a public health mission that revolves around specific disorders.

Q. In your opinion, is this a shift in emphasis?

A. Well, the mission statement, as you had it in your first question about reducing the burden, is one that I inherited...I was reading a statement from about 1996 when the institute did a retrospective of 50 years of leadership at NIMH. They had comments from six or seven previous directors, and what was interesting was that virtually every one of them spoke about the public health mission of the NIMH. It's certainly not new in that sense. This goes back as long as NIMH has been NIMH.

Q. You've stated previously that the NIMH must prioritize and not spread itself too thinly. What areas will the institute focus on in particular, and what areas will be de-emphasized?

A. A general area for us is what we now call translational research. It's taking research that bridges the revolution that is taking place in biology and in neuroscience and finding a way to have that science inform our understanding and our treatment of disorders...We have an opportunity here that is unparalleled in this history of the field. We can now really begin to make some progress on fundamental questions relevant to mental disorders using basic science and begin to apply it better.

I should emphasize that basic science in this case isn't just molecular and cellular, but also behavioral and cognitive science, which can now be applied to these very mysterious disorders.

Q. Can you elaborate on how behavioral science can be applied to these disorders?

A. One of the things we now understand is that a huge part of the disability associated with schizophrenia is the deficit in cognition, especially executive function and working memory. We really need the very best science on working memory to help inform how we can go about helping people with this deficit.

Q. You're often quoted as saying that NIMH should focus on "discovery-driven science." Can you explain what you mean by that?

A. That is a bit of a jargon term these days, and it comes out of the recognition that biology has become much more of an information science. For instance, with the human genome, we recognize that there are about 30,000 genes, and yet we only have functional information on perhaps 1 to 3 percent of that 30,000. There is a great interest...in trying to get an understanding of the other 90-plus percent of the genome, particularly because more than half of the genome is expressed in the brain...When we say "discovery-driven," what we're talking about is that we aren't even ready yet to develop the theories about most of the 16,000 genes that are expressed in the brain because at this point we don't have any information about them with which to develop a theory. We're at the stage of just beginning to discover where and when they are expressed. That's a huge challenge for us, and one that is vital for us and the brain institutes in general to embrace.

Q. Does refining theories of cognition and behavior in general also have a place in the portfolio of NIMH?

A. Sure. It's going to be important for us to push the science of cognition and behavior in a number of directions. One place will be to link this science more closely to biology, not only because we have the tools now to do that, but because as we, for instance, link cognition to the brain, and we link behavior to specific genes and specific neural circuits, we find new insights that enrich the study of cognition and behavior. Look at how neuroimaging has changed our understanding of linguistics or face processing--areas that are critical for our understanding autism. So it's going to be important for progress in those fields to really begin to apply the very best tools that we have available in terms of linking them to biology, and it's important to NIMH to ultimately link this understanding of behavior and cognition to mental disorders.

Q. As you know, a lot of the talk about NIMH is centering on budgetary challenges. How will limited budgetary increases affect the institute?

A. Well it's a good question. There are really three issues we are dealing with here, and I think they all converge. The first issue is that we have a dramatic increase in the number of applications. The number of applications has gone up about 40 percent from 1998 to 2002, but in this last six months we have seen about a 25-percent increase from the 2002 level.

There's also an increase in the average cost per application, which has also gone up about 40 percent in the last five years. So, given a fixed amount of money, these two things together mean we can fund fewer grants, and the percentile for how many proposals we are funding is going to drop.

Now over the past four to five years, it was possible to keep the percentile up with the increase in number of applications and the increase in cost because we were looking at 12-and sometimes 13-percent increases per year in our budget. That's the third factor, and that factor has changed. We are now looking at increases that are around 3 percent or even less.

Q. What accounts for the increased cost of applications?

A. Well, the biggest reason is that clinical applications have become more expensive....It is more expensive to do clinical research than it was. So we see that increase, along with the increase in the number of applications, the fact that we're not going to have a lot of new money, and it means that our payline is going to drop. And it means there is going to be less money available for expensive new ventures.

Q. There have been some recent congressional objections to certain NIH grants. How is NIMH being affected by these inquires?

A. In fact, most of these inquiries have come to NIH central, so we are getting questions indirectly. I might say the only one that has really gotten to the level of a congressional inquiry has been one that looked at five grants--NIMH had one of the five--several months ago. It was Congressman Toomey who raised the question about the relevance of specific grants to public health.

Most of those grants dealt with research into HIV, and NIMH is very committed to doing research on AIDS transmission, which is after all a behavioral problem. We are committed to reducing the burden of illness from AIDS by changing behavior that leads to transmission of HIV.

Q. Can psychologists assist NIMH in protecting the peer-review system from congressional interference?

A. I can't tell you at this point, from where I sit, that there has been congressional interference in the peer-review system. We're concerned any time politics tries to trump the scientific process, particularly the peer-review process, which we think should be completely free of political interference. From my perspective, it generally has been.

The one place where this became an issue was from these five grants, which Congress almost voted to defund. That is very worrisome, and it's something that the scientific community needs to be vigilant about. Because at the point when Congress is beginning to weigh in on individual NIH grants that have already been funded, then the community needs to recognize that the question is not just about those individual grants but the entire system by which we determine scientific excellence.

Q. How will the NIH Roadmap--a comprehensive NIH plan that promotes collaboration, and sometimes shared funding pools, between institutes--affect the overall NIMH budget and strategic plan?

A. We're excited about the Roadmap. The Roadmap was put together to try to enable all the institutes to work in a cooperative fashion to overcome some obstacles to scientific progress. We see it doing this in some very key areas--particularly areas of clinical research. In terms of budget, the amount of money that is going to be expended is not that great; it's certainly going to be less than 1 percent of the NIH budget.

The important thing for the APA membership to understand is that 1 percent of the budget is going to be put into a pool that is open for everyone to compete for. It will be important that we see NIMH grantees competing for that pool so that we can be certain that the money that NIMH is putting into the general pool will ultimately come back to its grantees.

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